Dying in Hospital May Be Preferable to Dying at Home

NEW YORK--About 60% of the US population dies in the hospital, and manyhave questioned whether hospitals are the best place to care for the dying.However, the hospital setting offers many advantages, Myra Glajchen, DSW,said during a teleconference sponsored by Cancer Care Inc.

"Hospitals have gotten short shrift in the debate. They have beenunfairly portrayed as the bad guys," said Dr. Glajchen, educationalcoordinator of the Department of Social Work, Memorial Sloan-KetteringCancer Center.

The greatest advantage hospitals have to offer the dying is clinicalcompetence, she said. A high level of clinical competence includes bothmanagement of the physical symptoms that are typical of the end of life(pain, fatigue, dyspnea, and nausea and vomiting) and management of thepsychological symptoms (anxiety, depression, agitated delirium, dysphoria,and a sense of loneliness).

Access to Latest Technology

"Hospital care at the end of life offers access to the latest medicaltechnology, a team of experts available 24 hours a day, constant monitoringof side effects and immediate treatment if they occur," Dr. Glajchensaid.

Families benefit from the social support of being in the hospital. "WhenI walk through the waiting room at Sloan-Kettering, I see families sittingtogether for hours, going together to the cafeteria," she said. "Thereis something comforting and safe about being there--and also about havingthe option of leaving at the end of the day, going home, and getting somerest and respite, which one doesn't always have when caring for an illrelative at home."

A hospital can also offer families a more rapid sense of closure aftera loved one dies. "They can leave the hospital and never come back,and many of them really don't like to step back into that environment,"she said, "whereas when a loved one dies at home, closure may takemore time."

Finally, in terms of financial issues, insurance coverage is usuallybetter for patients dying in the hospital rather than at home or in a hospice,she said.

Disadvantages of Hospital Care

Dr. Glajchen acknowledged that hospitals also have some shortcomingswhen it comes to care of the dying. For example, patients in a teachinghospital have little privacy. "There are always groups of studentsand specialists and members of the team coming and going," she said.

Lack of control and lack of regard for patients' preferences are themost often cited reasons patients do not want to spend their last daysin a hospital. "They feel they get unwanted medical attention in thehospital, even when they have advance directives and have been very clearabout what they do and do not want at the end of life," she said.

Dr. Glajchen believes that much of this concern is due to miscommunicationand misunderstanding. "It's sometimes difficult to achieve a goodfit between what the patient states is his preference, what the familyhears, and what the team members hear and can provide."

Finally, she said, patients can feel isolated in the hospital if familiesare not allowed to stay over or if patients are not encouraged to bringin items of comfort and familiarity from home.

Recommendations

As both health care professionals and the public have become aware ofthese problems, she said, many recommendations for improvement have beenmade. Dr. Glajchen outlined what she considers the most important.

• Advance directives. Opportunities must be created to discussdying and advance directives with patients and families. Family membersshould be referred to organizations like Choice in Dying that have trainedexperts who provide counseling and explain the documentation necessaryfor advance directives.

The patient's wishes must be honored, she stressed. In cases of familyor ethical conflict, the rest of the multidisciplinary team should be broughttogether to help solve these dilemmas.

Aggressive Palliative Care

• Palliative care. Aggressive palliative care and symptom managementmust be provided. There should be codes for palliative care available oninsurance forms so that inpatient palliative care can be reimbursed. Hospitalcharts should also provide a section for palliative treatment.
• Support for families. "This is an excellent time to offerpastoral counseling and bereavement counseling," Dr. Glajchen said."And for the patient who is dying, it is comforting to know that therewill be help for their family members afterward."

Hospitals also need to provide a mechanism for getting feedback fromfamilies so they can evaluate the quality of care and support they provided,and learn from this information where more work is needed.

• Staff support groups. A staff support group should be implementedto prevent burn out, facilitate shared learning, and give staff a senseof closure when patients die after a lengthy hospital stay.